Does a patient with a colonoscopy showing obstructive tumors in the distal sigmoid and proximal rectum, suspicious for malignancy, and biopsy results indicating tubular adenoma with high-grade dysplasia, require referral to oncology or general surgery?

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Last updated: May 27, 2025 • View editorial policy

From the Research

This patient should be referred to a general surgeon for further management due to the presence of high-grade dysplasia in the sigmoid colon biopsy, which represents a pre-cancerous condition requiring complete surgical removal to prevent progression to cancer. The colonoscopy revealed obstructive tumors in the distal sigmoid and proximal rectum that appeared suspicious for malignancy, but the pathology results showed tubular adenoma with high-grade dysplasia and a hyperplastic polyp rather than invasive cancer. According to a recent study 1, high-grade dysplasia is associated with an increased risk of colorectal cancer, and surgical resection is recommended to prevent progression to cancer.

The surgical approach is necessary because high-grade dysplasia, especially in a large obstructive lesion, carries significant risk of harboring unsampled areas of invasive cancer despite the current biopsy results showing only dysplasia. Additionally, the obstructive nature of these lesions presents a risk for bowel obstruction that requires surgical intervention. A general surgeon would be the appropriate specialist to perform a segmental colectomy or similar procedure to remove these lesions completely. If subsequent pathology after surgical resection reveals invasive cancer, then oncology referral would be warranted for consideration of adjuvant therapy.

Some studies suggest that endoscopic resection may be feasible for high-grade dysplasia in certain cases 2, but the presence of obstructive tumors and the risk of bowel obstruction make surgical intervention the most appropriate course of action in this case. Other studies have highlighted the risk of recurrence with malignancy after endoscopic resection of large colon polyps with high-grade dysplasia 3, further supporting the decision for surgical management. Recent guidelines also recommend surgical resection for patients with invisible high-grade dysplasia, invisible multifocal low-grade dysplasia, and colorectal cancer 4.

In summary, the patient's condition requires prompt surgical attention to prevent potential complications and progression to cancer. Referral to a general surgeon is the most appropriate next step in management, and subsequent oncology referral may be necessary depending on the final pathology results.

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